Sample ID card and description of terms Back left Back right Front left Front right blueshieldca.com Providers: Please file all claims with your local BlueCross BlueShield licensee in whose service area the member received services or, when Medicare is primary, file all Medicare claims with Medicare. California Providers: Call Provider Customer Service to obtain medical and hospital admission prior authorization to avoid reduced or non-payment; Pharmacistscall for prescription processing information. Visit Provider Connection at: blueshieldca.com/provider. CA Medical claims to: Blue Shield of California, P.O. Box 272540, Chico, CA 95927-2540 (800) 642-6155 Member Services (800) 241-1823 TTY (877) 263-9952 Mental Health Customer Svc. (877) 304-0504 NurseHelp 24/7 (800) 985-2405 LifeReferrals 24/7 (800) 810-2583To locate providers outside of California (800) 541-6652CA Provider Customer Service (including hospitals) (888) 635-8224 Pharmacists Only Blue Shield of California is an independent member of the Blue Shield Association. Blue Shield of California a b c d Subscriber JOHN DOE ID# XEHJ02388023 Copayments Office $25 Hospital $200 Emergency$100 e g Group # Effective Plan H12187 01/01/13 HMO Rx Yes f SF HEALTH SERVICE SYSTEM Back left This information is used by physicians and providers. Back right Member services numbers and addresses to submit claims. Front left a Member name – your name b Member ID number cPCP/SPC – indicates the primary care physician (PCP)/ specialist (SPC) office visit copays dER – indicates emergency room (ER) copay Front right eGroup# and Plan – shows type of coverage fEffective date – the date you became covered by our plan gThis information is required by pharmacies to electronically bill prescriptions. blueshieldca.com/sfhss Inside left MEDICAL GROUP NAME JANE DOE, MD (415) 123-4567 JOHN DOE Effective 01/01/13 k JOHN DOE, JR. Effective 01/01/13 Members: In case of emergency, call 911 or seek appropriate emergency care. As soon as possible after receiving care, please contact your personal Physician. Carry this ID card with you at all times and present it to your Personal Physicianwhenever you receive care. It is important to follow the procedures explained in your Evidence of Coverage booklet. If you have any questions about your benefits, your copayments,or your prescription drug coverage, call Member Services. A+ gives you the option to self-refer to an Access+ Specialist, subject to certain limitations. See your Evidence of Coverage for details. Inside right This information is for you to read in case of emergency, if you are billed in error or need help locating network pharmacies. A45760 (4/13) Inside left j Name of your Personal Physician k Name of your medical group or IPA An Independent Member of the Blue Shield Association j Inside right Sample ID card and description of terms Back left Back right Front left Front right blueshieldca.com PhysiCians and Providers: <plan name> (HMO) Member Services Prior approval: Telephone the physician named on this card prior to treatment in a non-emergency. Provision of routine treatment without prior authorization may result in non-payment. Note: This card is for identification only. emergency care: Telephone the physician named on this card as soon as possible after treatment. note: This card is for identification only. Call the number on the reverse side of this card to verify eligibility. PhysiCians and Providers: (877) 654-6500 elibility verification Blue Shield of California is an independent member of the Blue Shield Association. (800) 776-4466 (800) 794-1099 TTY submit Medical claims to: Blue Shield 65 Plus P.O. Box 272640 Chico, CA 95927-2640 submit rx claims to: Blue Shield of California Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168 i Back left This information is used by physicians and providers. Back right Member services numbers and addresses to submit claims. i Address for you to send out-of-network prescription claims to a b Member c Copayments PCP/SPC $XX/XX ER $XXX $XXX AMB d John doe Membership number XeaJ1234567801 e g Plan Group No. Card issued Plan code <plan name> (hMo) Mrd100 12/1/12 Bs1 RxBin RxPCN Issuer 012353 01920000 80840 CMS H0504-015 f h Front left a Member name – your name b Member ID number c PCP/SPC – indicates the primary care physician (PCP)/ specialist (SPC) office visit copays Note: Refer to your Evidence of Coverage for complete benefit information. The information provided on your ID card is to be used as a quick reference only. Benefits are not limited to this information. d ER – indicates emergency room (ER) copay e AMB – indicates ambulance (AMB) copay Front right f Group No. and Plan – shows type of coverage g Card issued – the date your most recent card was issued to you h This information is used by pharmacies to electronically bill prescriptions. H0504_12_364 10152012 blueshieldca.com Inside left MEMBERS: John doe, Md (555) 555-5555 (877) 304-0504 NurseHelp 24/7 (800) 855-2881 TTY ABC Medical Grp 123 Main St Anytown, CA 00000 in an emergency: Call 911 or immediately go to the nearest hospital emergency room for treatment. HOSPITAl INFORMATION: out-of-area urgent care: If you are outside the health plan area and need medical attention right away for an unforeseen illness or injury, go to the nearest medical facility. Notify Blue Shield 65 Plus or your primary care physician at the time of service or as soon as possible after treatment. aBC hospital (555) 555-5555 123 Main St Address line 2 Anytown, CA 00000 Inside left j Name of your primary care physician k Name of your medical group or Independent Practice Association (IPA) l Billing and member services: Network providers have agreed not to bill Blue Shield 65 Plus members. Contact Member Services if you are billed in error or if you need other assistance with claims or billing. For information on locating network pharmacies: Call Blue Shield 65 Plus Member Services. Inside right This information is for you to read in case of emergency, if you are billed in error or need help locating network pharmacies. Hospital name and address A35138 (10/12) l PHYSICIAN INFORMATION: An independent member of the Blue Shield Association j k Inside right Sample ID card and description of terms Front Back blueshieldca.com a b Member John Doe c Plan Card issued <plan name> (PDP) 12/15/12 Submit Rx claims to: Blue Shield of California Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168 Membership No. XEAJ1234567801 RxBin RxPCN RxGrp Issuer 012353 03510000 MRD300 80840 CMS S2468-004 e <plan name> (PDP) Member Services (888) 239-6469 (888) 239-6482 Blue Shield of California is an independent member of the Blue Shield Association. Member Services TTY f d Front a Member name – your name b Member ID number c Card issued – the date your most recent Back e Address for you to send out-of-network prescription claims to f Member Services toll-free number card was issued to you An independent member of the Blue Shield Association to electronically bill prescriptions. A35145 (10/12) d This information is used by pharmacies S2468_12_364 10152012 blueshieldca.com